The initial experience of 2495 cases of the ulnar artery as default access for coronary diagnostic and interventional procedures at a single center: An observational study.

INTRODUCTION: Upper limb arterial access is being increasingly used for coronary diagnostic and intervention procedures. Radial artery access is associated with reduced morbidity and mortality as compared to femoral artery access. However, access to the radial artery is not always successful with reported crossover rates to other routes between 3% and 8%. Ulnar artery access is emerging an attractive option both as upfront access and rescue access in case of failure to obtain radial artery access. AIMS -: To assess and document the feasibility and safety of ulnar access as a default strategy. METHODS: 2654 patients planned for coronary diagnostic and intervention procedureswere assessed for inclusion. Inclusion criteria were, all patients planned for coronary angiography (CAG) or percutaneous coronary intervention (PCI) with palpable ulnar pulse. Exclusion criteria included reverse Barbeau test type D, previous procedure resulting in radial artery occlusion/excision, hemodialysis patients having ipsilateral AV fistula and severe forearm deformities. RESULTS: 2525 patients were found eligible, out of which 2495 (98.81%) were successfully cannulated. Procedure was completed in 2414 patients. Local site bleeding in 40 (1.6%) and acute loss of ulnar pulse noted in 33 (1.3%) out of 2495 patients. None of the patients had gangrene of access site, pseudo-aneurysm, arteriovenous fistula or neurological deficit post procedure. CONCLUSION: The Ulnar artery access as a default access is safe and feasible option for patient undergoing coronary diagnostic and interventional procedures.

Ivabradine vs metoprolol in patients with acute inferior wall myocardial infarction-"Expanding arena for ivabradine".

BACKGROUND: Atrioventricular (AV) blocks are of concern with the use of beta blockers in inferior wall myocardial infarction (MI). Ivabradine lowers heart rate with a lesser risk of AV blocks. OBJECTIVES: To compare ivabradine with metoprolol in acute inferior wall MI in terms of feasibility, tolerability, and efficacy. METHODS: It was a prospective double-blind single-center randomized controlled study. Of 1032 patients with acute inferior wall MI, 468 eligible patients were randomized in 1:1 manner to ivabradine (group A) and metoprolol (group B). Intention to treat analysis of 426 patients (group A-232 and group B-232) was performed. The primary endpoint was 30-day incidence of major adverse cardiovascular events including death, reinfarction, complete heart block (CHB), and heart failure. Secondary endpoints included 30 days incidence of recurrent angina, readmission, first- or second-degree AV block, and tachyarrhythmias. RESULTS: Both the drugs decreased the mean heart rate to 62.22±2.95 (group A) vs 62.53±3.59 (group B) beats per minute (P=0.33). Ejection fraction improved in both the groups (5.15±1.93% in group A vs 5.52±2.18% in group B, P=0.065). The two groups did not differ significantly in their primary endpoints in terms of death (group A=1.72% vs group B=1.72%, OR=1.00, 95% CI=0.25-4.05, P=1.00), reinfarction (group A=0.86% vs group B=0.86%, OR=1.00, 95% CI=0.14-7.16, P=1.00), heart failure (group A=4.31% vs group B=2.59%, OR=1.70, 95% CI=0.61-4.75, P=0.31), or CHB (0% vs 2.59%, OR=0.07, 95% CI=0.00-1.34, P=0.08). There were no significant differences in the secondary endpoints of recurrent angina, readmission, and tachyarrhythmias except for more first- and second-degree AV blocks with metoprolol (12.93% vs 2.59%, OR=5.59, 95% CI=2.28-13.72, P=0.0002). CONCLUSIONS: Ivabradine is well tolerated and equally effective as metoprolol in acute inferior wall ST elevation myocardial infarction patients for lowering the heart rate with lesser risk of AV blocks.

3D Xplane Echocardiographic Technique for Validation of Mitral Leaflet Separation to Assess Severity of Mitral Stenosis.

BACKGROUND: Determining the severity of mitral stenosis (MS) is important for both prognostic and therapeutic implications. Mitral valve area (MVA) calculation techniques have more limitations. Mitral leaflet separation (MLS) is a precise and operator friendly alternative to planimetry. In contrast to previous researchers, we have used a novel 3D Xplane technique to validate MLS for assessing the severity of MS. 3D Xplane is superior for validation of MLS due to simultaneous real time acquisition of MLS in parasternal long-axis view and corresponding MVA by planimetry in parsternal short-axis view. METHODS: It was a prospective observational single center study. A total of 174 patients with MS were evaluated for MVA estimation by various echocardiographic modalities. Maximum leaflet separation and corresponding planimetered MVA were measured using novel 3D Xplane technique. RESULTS: With 3D Xplane technique, there was strong positive correlation between planimetered MVA and MLS (R = 0.925, P < 0.001), irrespective of coexisting MR (R = 0.886, P < 0.001) or AF (R = 0.912, P < 0.001). Receiver operating characteristic curves of MLS demonstrated AUC for mild and severe MS to be 0.966 and 0.995, respectively. MLS less than 8.62 mm predicted severe MS with 95.5% sensitivity and 94.7% specificity and MLS more than 12.23 mm predicted mild MS with 93.2% sensitivity and 91.4% specificity. CONCLUSION: In our study, a strong correlation between planimetered MVA and MLS was found using 3D Xplane technique. 3D Xplane thus validates and standardizes MLS by excluding errors due to temporal and spatial variations which are important limitations of 2D echocardiography.

Sweating: A Specific Predictor of ST-Segment Elevation Myocardial Infarction Among the Symptoms of Acute Coronary Syndrome: Sweating In Myocardial Infarction (SWIMI) Study Group.

BACKGROUND: Today, cardiologists seek to minimize time from symptom onset to interventional treatment for the most favorable results. HYPOTHESIS: In the acute coronary syndrome (ACS) symptom complex, sweating can differentiate ST-segment elevation myocardial infarction (STEMI) from non-ST-segment elevation ACS (NSTE-ACS) during early hours of infarction. METHODS: This single-center, prospective, observational study compared symptoms of STEMI and NSTE-ACS patients admitted from August 2012 to July 2014. RESULTS: Of 12 913 patients, 90.56% met ACS criteria. Among these, 22.51% had STEMI. Typical angina was the most common symptom (83.82%). On stepwise multiple regression, sweating (odds ratio: 97.06, 95% confidence interval [CI]: 82.16-114.14, P < 0.0001) and typical angina (odds ratio: 2.72, 95% CI: 2.18-3.38, P < 0.001) had significant association with STEMI. For diagnosis of STEMI, positive likelihood ratio (LR) and positive predictive value (PPV) were highest for typical angina with sweating (LR: 11.17, 95% CI: 10.31-12.1; PPV: 76.09, 95% CI: 74.37-77.75), followed by sweating with atypical angina (LR: 3.6, 95% CI: 3.07-4.21; PPV: 50.61, 95% CI: 46.45-54.76), typical angina (LR: 1.05, 95% CI: 1.03-1.07; PPV: 22.97, 95% CI: 22.11-23.84), and atypical angina (LR: 0.77, 95% CI: 0.69-0.87; PPV: 18.09, 95% CI: 16.32-19.97). C statistic values of 0.859 for typical angina with sweating and 0.519 for typical angina alone reflected high discriminatory value of sweating for STEMI prediction. CONCLUSIONS: Presence of sweating with ACS symptoms predicts probability of STEMI, even before clinical confirmation. Sweating in association with typical or atypical angina is a much better predictor of STEMI than NSTE-ACS.

Prevalence of congenital heart disease in patients undergoing surgery for major gastrointestinal malformations: an Indian study.

BACKGROUND: The association of congenital heart disease (CHD) with malformations of the gastrointestinal (GI) tract/abdominal wall is known. The rates of cardiac malformations reported in previous studies of these anomalies are highly variable. OBJECTIVE: To find the prevalence and pattern of CHD in patients with major gastrointestinal malformations (anorectal malformations, oesophageal atresia/tracheo-oesophageal fistula, and omphalocoele) undergoing surgery at a tertiary care hospital in India. METHODS: From July 2012 to December 2013, 43 patients (34 (79%) male, 9 (21%) female) were evaluated by clinical examination, ECG, chest radiography, and colour Doppler echocardiography. RESULTS: Of the 43 patients, 26 (60.46%) had CHD. The most common GI malformation was anorectal malformation: 32 cases (74.41%), of whom 16 (50%) had CHD. The second most common malformation was oesophageal atresia/tracheo-oesophageal fistula: 5 cases (11.62%), all (100%) with CHD. The third group comprised patients with omphalocoele: 4 cases (9.3%), 3 of whom (75%) had CHD. The fourth group comprised patients with VACTERAL (vertebral anomalies, anal atresia, cardiovascular malformations, tracheo-oesophageal fistula, renal and limb anomalies) association-2 cases (4.6%), all (100%) with CHD. The most common CHD was isolated atrial septal defect (ASD) (73%), followed by ASD + ventricular septal defect (VSD) + patent ductus arteriosus (PDA) (7.6%), ASD + VSD (3.8%), ASD + PDA (3.8%), VSD (3.8%), PDA (3.8%), and coarctation of the aorta (3.8%). CONCLUSIONS: We found the frequency of CHD in patients with GI malformations was very high, the most common presentation being ASD. Our study indicates the need for larger scale studies to determine the prevalence of CHD in patients with GI malformations in the Indian population.

A single center multioperator initial experience of 4,195 patients at a primary radial intervention program in a tertiary level center.

BACKGROUND: There has been an increase the acceptability and the number of the procedures via the radial approach. We present our experience pertaining to the clinical characteristics, procedural details and post procedural outcome of patients undergoing radial artery access, coronary angiographies over a period of 4 years at a primary care tertiary level center. MATERIALS AND METHODS: A retrospective analysis of all the coronary artery procedures during the last 4 years was done and the various parameters related to these procedures noted. RESULTS: In 4195 procedures performed, success in radial artery procedures was achieved in 3975 (94.8%) procedures. The average puncture time and total procedure time was 9.5 + 3 min (min) and 15 + 2.5 min in the initial 500 patients, whereas the times taken in the final 695 patients were just 1.5 + 0.5 min and 3.0 + 1.5 min respectively. The total fluoroscopy time was not significantly different among the groups, when performed by an operator with training in the femoral route for angiography. Cardiology fellows needed more fluoroscopy time when mastering the radial route. Crossover of access sites was seen in 220 patients (5.2%). CONCLUSIONS: After 100 procedures, radial access coronary angiographies take less than 4.5 min, with first attempt radial artery access and negligible complication rates. Prior experience of coronary angiography helps in the reduction of fluoroscopy time during the learning curve.

Characteristics of radial access site coronary procedures in patients with arteria lusoria among 5789 patients undergoing coronary angiography at a primary radial access centre.

BACKGROUND: Anatomical obstructions are the bane of radial access site for coronary procedures for inexperienced operators. The availability of better hardware in the performance of procedures by this route has mitigated this problem. Arteria lusoria (AL) is a congenital anomaly which predisposes to access site crossover during the early phase of the learning curve. We present our experience in the performance of radial access site coronary angiographies of these patients, which is the first such study reported in literature. MATERIALS AND METHODS: Retrospective analysis of 5879 patients from August 2006 to August 2012 was done with special attention to preprocedural and peri-procedural parameters in patients with AL. Analysis of the angle made by the aberrant vessel with the arch of aorta is also noted. Comparisons were made with timings of radial angiography as reported by Looi et al. Comparison was made of the time taken to complete the procedure by the operator vis-a vis the time taken during earlier performance of the procedure in these patients by the same operator. RESULTS: The incidence of AL is 0.5%. The total time taken for the procedure is 18.1+6.9 min and the total fluoroscopy time needed is 4.0+2.7 min. Comparisons with the study conducted by Looi et al reveal no statistical significance between the times (p>0.05). When stratified with respect to the experience of the performing operator, there was significant difference (p<0.001) in the total time taken and the total fluoroscopy time required for the procedure when performed with experience of previous angiographies via the radial route. The aberrant vessel made an angle of 45° on an average with the arch of aorta. With experience, the number of guiding catheters needed for the procedure decreased from four to one and the operator was able to perform the procedure with the same catheter. Peri-procedural complications of vasospasm and minor bleeds were the only ones to attain statistically significant increase in these patients (p<0.05) and were related to higher duration of the procedure and unrelated to the age and sex of the patient. CONCLUSIONS: AL is not a contraindication to the performance of coronary angiography. Experience of the operator helps in achieving procedure and fluoroscopy times akin to that of routine radial angiography.